Military Medicine最新文献

Historically, military anatomic pathology (AP) services have been significantly compartmentalized, with each branch independently executing its laboratory support mission. The result is redundant and costly duplication of nearly identical services in close geographic proximity. The duplication of AP services disperses the overall caseload, resulting in pathologist diagnostic acumen atrophy, excessive support personnel requirements, inadequate utilization of subspecialty expertise, and overall lower-quality patient care. Unlike many medical specialties, implementing AP services does not require direct patient interaction and is principally not as time-sensitive as other clinical laboratory testing. The practice of AP is conducive to a more consolidatory paradigm to achieve economies of scale. Pathology service unification would also afford the stationing of predominantly subspecialists at tertiary care centers to handle higher caseloads. Larger groups of pathologists increase patient safety enhancing peer-to-peer and subspeciality quality assurance processes during case review. Conversely, the nature of clinical pathology services requires a more widespread presence-even at the smaller, auxiliary clinics throughout the military health system. Clinical pathology services would also benefit from additional triservice cooperation including standardization of quality management processes, increased resource sharing, exchange, and cooperative contingency planning. Laboratory directorships also benefit from consolidating expertise, where pathologists could be physically located at a central site with remote oversight of laboratory services. Here, we propose a holistic triservice consolidation plan for military pathology to optimize resource utilization and ultimately realize the overarching strategic plan for military medicine set forth by the Defense Health Agency.

Introduction: Military satisfaction is an important determinant for military retention and subsequently military readiness. Military readiness is also impacted by food insecurity, which affected 25% of active duty service members in 2018 and 2020, much higher than the 10% prevalence observed in civilians. The objective of this study is to estimate the association between food insecurity and 3 indicators of satisfaction with military life: active duty service member's overall satisfaction with military life, active duty service member's intent to leave the military, and married active duty service members' perceptions regarding spousal desire to leave the military.

Materials and methods: The 2020 Status of Forces Survey of Active Duty Members is a probability-based sample of all active duty service members in the U.S. Military (n = 12,324). Weighted logistic regressions were used to estimate the associations between food insecurity and retention indicators controlling for observable confounders. This study was approved as public health practice by the Defense Centers for Public Health-Aberdeen.

Results: Respondents with either low food insecurity (adjusted odds ratio (AOR): 1.45; 95% confidence interval (CI), 1.18-1.78) or very low food insecurity (AOR: 1.68; 95% CI, 1.30-2.16) had greater odds of dissatisfaction with military way of life compared to food secure respondents. Additionally, very low food security was associated with greater odds of spousal desire to leave the active duty military. Respondents who reported they had lower levels of financial security had lower satisfaction with the military way of life, greater intent to leave the military, and greater spousal desire to leave active duty.

Conclusions: In the present era of an all-volunteer military, novel strategies are needed to recruit and retain service members and their families. Although food insecurity was only associated with overall satisfaction with the military way of life, lower financial security was associated with satisfaction and intent to leave the military. Future studies could determine how financial security, including food insecurity, can be bolstered among active duty service members to increase retention and maintain military readiness.

Introduction: This narrative review highlights the impact and epidemiology of post-COVID conditions (PCC, 'Long COVID') in military service members and beneficiaries, characterizing the threat of Long COVID to military readiness. We leveraged this review to propose a Long COVID research road map for Military Health System (MHS)-based studies, identifying key questions and knowledge gaps that the Department of Defense research enterprise is well-positioned to address.

Materials and methods: We searched MEDLINE (PubMed) in addition to MHS conference abstracts and websites, bibliographies of relevant published articles and https://clinicaltrials.gov/.

Results: Multiple studies in U.S., U.K., and European military service members have noted medically attended and patient reported post-acute sequelae and symptoms across the domains of cardiorespiratory, neurocognitive, and mental health. Studies have also noted an association with SARS-CoV-2 infection and fitness in young adult service members, but the ongoing prevalence, morbidity, and functional impact of Long COVID in military populations in the current era remains unclear. All identified studies have limitations.

Conclusions: Considerable research has been conducted to understand the risk of and risk factors associated with Long COVID in active duty, much in the earlier pandemic period. Future research priorities include establishing Long COVID definitions most relevant to active duty personnel and conducting studies to delineate, treat, and prevent Long COVID's impact on cognitive, cardiorespiratory, and overall health and fitness for duty. Many considerations in this review article may also apply to post-acute sequelae from other infectious diseases, which pose risks to military health and readiness, including future respiratory virus pandemics.

Introduction: An estimated 5.6 million individuals in the U.S. experience limb loss and absence, but national estimates exclude Military Health System (MHS) beneficiaries. The purpose of this study is to characterize MHS beneficiaries with limb loss and absence and estimate incidence and prevalence.

Material and methods: We conducted a retrospective cohort study using data from the MHS Information Platform. Descriptive statistics were used to characterize the study population, including demographics, level of limb loss and absence, and etiology. Bivariate analyses between demographic characteristics and level of limb loss were conducted using analysis of variance and chi-square tests. The sample includes MHS beneficiaries diagnosed with limb loss or absence from 2005 to 2023. The study was determined exempt human subjects research by the Uniformed Services University of the Health Sciences Institutional Review Board.

Results: The cohort (118,587) was 64.6% male and 35.4% female, with mean age 58 years (SD = 23.4). Racial distribution included 49.8% White, 6.4% Black, and approximately 42.1% other or unknown. Service branches were Army (41.0%), Air Force (26.7%), Navy (19.7%), Marine Corps (7.0%), other (3.9%), Coast Guard (1.7%), and Space Force (0%). The majority were retired (46.2%) or other (32.0%), with a smaller portion active duty (12.0%) and dependents (9.9%). Levels of limb loss were 72% lower limb, 26.1% upper limb, and 2% unspecified. Causes included acquired absence (53.8%), traumatic amputation (34%), and congenital absence (12.1%). Bivariate analysis showed significant associations between demographics and limb loss levels (P = .000). Incidence (z = -2.43, P = .015) and prevalence (z = -13.69, P = .000) rates declined over 19 and 8 years, respectively.

Conclusion: This study highlights demographic characteristics, causes, and declining rates of limb loss and absence among MHS beneficiaries, providing a foundation for future research and informing clinical practices and policies to enhance care and resource allocation.

Introduction: Generating clinical narrative summaries is a critical use case for the Military Health System. This study evaluates the performance of detailed versus vague prompts in generating summaries that yield accurate, bias-free, and meaningful outputs.

Materials and methods: Eight anonymized large language models (LLMs) were evaluated by volunteer clinicians for clinical narrative summary generation from October through November of 2024. Eight clinical scenarios were presented to each model with structured and vague prompt variations, and the responses were evaluated for conformance, task adequacy, hallucinations, and bias.

Results: Both approaches were comparable in conforming to instructions (64%). The structured approach was more likely to produce a clinically adequate summary (39% compared to 9%) but also more likely to introduce hallucinations and bias.

Discussion: The structured prompt, following best practices for prompt engineering, produced a superior response but was prone to hallucinations. This could be mitigated with additional tuning. None of the models tested reliably produced clinically usable summaries.

Conclusion: Efficient generation of clinical summaries is critical for the Military Health System. Using a structured prompt that employs role, task, tone, and format increases the output quality. Institutions seeking to use LLMs to summarize clinical notes may have more success with a structured approach but need to be cautious in ensuring the summary itself is true to its source documents.

Gulf War Illness (GWI) is a condition that affects 30-40% of nearly 700,000 Veterans who were deployed to Operations Desert Shield/Storm/Sabre (ODS/S/S) between August 1990 and June 1991 and is characterized by a constellation of symptoms, including fatigue, mood/cognition, chronic pain, gastrointestinal (most frequently referred to as "irritable bowel syndrome"), respiratory, and skin issues. We review the development of various case definitions for GWI, as well as exposure theories. Despite heavy investment in research, both the pathophysiology and underlying cause of GWI remain areas of active inquiry. Similarities have previously been noted in symptomatology between GWI and myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), and more recently, long COVID (LC), a late effect of infection with the Severe Acute Respiratory Syndrome Corona Virus-2 (SARS-CoV-2). These conditions are discussed with respect to the similarities of their symptomatology and pathophysiology. Long COVID is a post-viral syndrome, and ME/CFS is widely considered to be likely post-infectious as well. This comparison leads to the proposal of the hypothesis that GWI may also be post-viral. Given the similarity of GWI and LC, it is possible that Veterans with GWI had an antecedent infection with a virus related to SARS-CoV-2, potentially the Middle East Respiratory Syndrome Coronavirus (MERS) or an ancestor of this virus. The MERS antibodies have been found in dromedary camels in Saudi Arabia since 1983 to the present, including the time of ODS/S/S. There is abundant evidence to support further investigation into this topic.

This case study describes the rehabilitation efforts of a 25-year-old male reserve officer who sustained a penetrating intraocular metallic foreign body (IOFB) injury to his right eye during a military conflict. Penetrating ocular trauma can lead to severe tissue deformities, scarring, permanent visual impairment, and long-term complications like intraocular infection and ocular hypotension. The patient's initial presentation revealed vision loss, pain, irritation, a foreign body sensation, and discomfort in the right eye. Diagnostic imaging confirmed a severe globe rupture, including the presence of metallic IOFB in the retina, retinal incarceration, and detachment with severe macular damage, necessitating surgical intervention, including repair of globe rupture, lensectomy, pars plana vitrectomy, IOFB removal, and filling of the vitreous cavity with silicone oil. Despite these surgical measures, visual acuity in the right eye remained hand motion at 15 cm with maintained peripheral vision and traumatic ptosis. A specialized scleral contact lens was fitted. This improved acuity to 6/60 additionally provided a magnifying effect, clinically improving near vision acuity to 6/30. The scleral lens improved the patient's dry eye indices, evidenced by decreased corneal staining and increased margin-to-reflex distance, improving esthetics. This case highlights the potential benefits of a scleral contact lens after severe penetrating eye injuries where even advanced surgical interventions may not fully restore vision. It significantly improved visual function and comfort by alleviating dry eye symptoms and simultaneously provided psychosocial benefits by masking cosmetic imperfections.

Introduction: Declining surgical case volumes in the Military Healthcare System have raised concerns about the readiness of Department of Defense (DoD) surgeons for deployment. Reduced opportunities for major surgeries at Military Treatment Facilities correlate with declines in surgical Knowledge, Skills, and Abilities metrics, which measures deployment preparedness. This challenge, termed the "Walker Dip," is exacerbated during peacetime. International surgical missions and military Global Health Engagement (GHE) have been proposed to bridge this gap by offering military surgeons the chance to manage complex cases in low-resource settings. Although GHE missions aim to strengthen global partnerships and improve interoperability, their direct impact on readiness remains unclear. This study evaluates military surgeons' perceptions of readiness following participation in DoD surgical missions to better inform future mission planning.

Materials and methods: An anonymous, voluntary survey was developed by medical students and military surgeons with GHE experience. Eligible participants were military surgeons with experience in DoD international surgical missions, excluding combat deployments and disaster response missions. The survey collected demographic data, mission characteristics, and participants' perceived readiness using Likert scales. Data analysis included descriptive statistics, chi-square tests, and Spearman's rank correlations.

Results: A total of 47 respondents met the inclusion criteria. The majority were general surgeons (72%), with 57% serving in the Navy. Fifty-five percent of participants rated the missions helpful to their readiness, while 44.7% were neutral or found them unhelpful. Key factors associated with mission helpfulness included managing complex cases, treating critically ill patients, and performing blood transfusions (P < .05). Although case complexity significantly correlated with perceived readiness (P = .002), case volume did not (P = .109). Navy surgeons were less likely to rate missions as helpful compared to Army and Air Force surgeons (P = .002).

Conclusion: This study highlights the critical role of case complexity and exposure to high-acuity patients in enhancing surgical readiness. International surgical mission planning for readiness should prioritize complexity and operational relevance over procedural volume. Further, optimizing mission design will ensure readiness and preparedness for future deployments while balancing global health and military objectives. Future research should explore standardized metrics to evaluate readiness and the long-term impact and ethical implications of these missions.

Introduction: Death by suicide remains a critical public health issue and leading preventable cause of death in the United States, particularly among Veterans. Notably, almost half of Veterans who attempt or die by suicide engage with the healthcare system in the days and months before these events, highlighting critical points for prevention and intervention.

Materials and methods: Utilizing the Suicide Prevention Applications Network (SPAN) database at a large Department of Veterans Affairs hospital in the Southeast, this Institutional Review Board (IRB) approved quality improvement project sought to document access and clinical care characteristics of Veterans who attempted or died by suicide over the course of a 10-year period. The data included 569 events among 497 unique Veterans (82.6% male, mean age = 45.62, SD = 15.00).

Results: Most events were suicide attempts (88.2%), whereas the remainder were suicide deaths. Almost half of the events involved an overdose, followed by firearms. Approximately two-thirds of Veterans were seen by a healthcare provider within 30 days of the event with most of these encounters occurring outside of mental health services. Over half of the Veterans had a prior attempt history, and though most had a safety plan documented, suicide was not discussed in approximately half of the last encounters.

Conclusions: These findings highlight opportunities for providers to screen for and utilize suicide prevention strategies, especially in non-mental health settings. The integration of brief, low-cost interventions, including consistent safety planning and follow-up communication across healthcare settings could enhance suicide prevention efforts and better support Veterans at risk.